NEW 2023 HESI EXIT RN EXAM

NEW 2023 HESI EXIT RN EXAM A male client who is admitted to the mental health unit for treatment of bipolar disorder has a slightly slurred speech pattern and an unsteady gait. Which assessment finding is most important for the nurse to report to the healthcare provider? (ANS- Serum lithiumlevelof 1.6 mEq/L or mmol/l (SI)—Rationale: The therapeutic level of Serum lithium is 0.8 to 1.5 mEq/Lor mmol/l (SI). Slurred speech and ataxia aresign of lithium toxicity. A client was admitted to the cardiac observation unit 2 hours ago complaining ofchest pain. On admission, the client's EKG showed bradycardia, ST depression, but noventricular ectopy. Theclient suddenlyreports a sharp increasein pain, telling the nurse, "Ifeel like an elephant just stepped on mychest" TheEKG now shows Q waves and ST segmentelevations in the anterior leads. What intervention should the nurse perform? (ANS- Administer prescribed morphinesulfateIV and provideoxygen at 2 L/min pernasal cannula. The nurseis developing a teaching program for thecommunity. What populationcharacteristic is most influential when choosing strategies for implementing a teaching plan? (ANS- Literacy level A client is being discharged with a prescription for warfarin (Coumadin). Whatinstruction should the nurse providethis client regarding diet? (ANS-Eat approximated thesame amountof leafy green vegetables daily so the amount of vitamin K consumed is consistent. A client who had a small bowel resection acquired methicillin resistantstaphylococcus aureus (MRSA) while hospitalized. Hetreated and released, but is readmittedtoday because of diarrhea and dehydration. It is most important for the nurse toimplement whichintervention. (ANS- Maintain contact transmission precaution A postoperative femaleclient has a prescription for morphine sulfate10 mg IV q3hours for pain. One doseof morphine was administered when theclient was admitted tothepost anesthesia care unit (PACU) and 3 hours later, the client is again complaining ofpain. Her current respiratoryrateis 8 breaths/minute. What action should the nurse take?(ANS- Administer Naxolone IV Which intervention is most important for the nurse to includein the plan of careforan older woman with osteoporosis? (ANS- Placetheclient on fall precautions Based on theinformation provided in thisclient's medical record during labor,which should the nurseimplement? (Click on each chart tab for additional information. Please besure to scroll to the bottom right cornerofeach tab toview all information contained intheclient's medical record.) (ANS- Continueto monitor the progress of labor. An unlicensed assistive personnel UAP leavesthe unit without notifying thestaff. In what order should the unit manager implement this intervention to addressthe UAPsbehavior? (Place the action in order from first on top to last on bottom.) (ANS- 1. Note dateand time of the behavior. 2. Discusstheissue privately with the UAP. 3. Plan for scheduled break times. 4. Evaluatethe UAP for signs of improvement. Following discharge teaching, a male client with duodenal ulcer tells the nurse hewill drink plentyof dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action bythe nurse? (ANS- Review with theclient the need to avoid foods that are rich in milk andcream A maleclient with hypertension, who received new antihypertensive prescriptionsat his last visit returns to theclinictwo weeks later to evaluate his blood pressure (BP). HisBP is 158/106 and he admits that he has not been taking the prescribed medicationbecause the drugs make him "feel bad". In explaining the need for hypertension control, thenurseshould stress that an elevated BP placestheclient at risk for which pathophysiologicalcondition? (ANS- Strokesecondaryto hemorrhage The nurse observes an unlicensed assistive personnel (UAP) positioning a newlyadmitted client who has a seizure disorder. Theclient is supine and the UAP is placing softpillows along thesiderails. What action should the nurse implement? (ANS- Instruct the UAP to obtain soft blankets to secure to the side rails instead ofpillows. An adolescent with major depressive disorder has been taking duloxetine(Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?(ANS- Describes life without purpose A 60-year-old female client with a positive family history of ovarian cancer hasdeveloped an abdominal mass and is being evaluated for possibleovarian cancer. HerPapanicolau (Pap) smear results are negative. What information should the nurseinclude in theclient's teaching plan? (ANS-Furtherevaluation involving surgery may be needed A client who recently underwear a tracheostomyis being prepared for dischargetohome. Which instructionsis most important for the nursetoinclude in the discharge plan?(ANS- Teach tracheal suctioning techniques In assessing an adultclient with a partial rebreather mask, the nurse notes that theoxygen reservoir bag does not deflatecompletely during inspiration and theclient'srespiratoryrate is 14 breaths/ minute. What action should the nurse implement? (ANS- Document the assessment data — Rational: reservoir bag should notdeflate completely during inspiration and theclient's respiratoryrateis within normallimits. During shift report, thecentralelectrocardiogram (EKG) monitoring systemalarms. Which client alarm should the nurseinvestigate firs?(ANS- Respiratory apnea of30 seconds During a home visit, the nurse observed an elderly client with diabetes slip andfall. What action should the nursetakefirst? (ANS- Check theclient for lacerations or fractures At 0600 while admitting a woman for a schedulerepeat cesarean section (CSection), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted toavoid getting a headache. Which action should the nurse takefirst?(ANS- Inform the anesthesia care provider After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2heart sounds. To determine if an S3 heart sound is present, what action should the nursetake first? (ANS-Listen with the bell at thesamelocation